Cognitive behaviour therapy for menopausal symptoms following breast cancer treatment: Who benefits and how does it work?

Objectives

Cognitive behaviour therapy (CBT) has been found to reduce the impact of menopausal symptoms, hot flushes and night sweats. This study investigates the moderators and mediators of CBT for women who had problematic menopausal symptoms following breast cancer treatment.

Study design

Analysis of 96 patients with breast cancer induced menopausal symptoms recruited to the MENOS1 trial; 47 were randomly assigned to Group CBT and 49 to usual care. Questionnaires were completed at baseline, 9 and 26 weeks post randomisation. Potential moderators and mediators, including sociodemographic, clinical and psychological factors, of the treatment effect on the primary outcome were examined.

Main outcome measure

Hot Flush Problem Rating.

Results

CBT was effective at reducing problem rating at 9 weeks regardless of age, BMI, time since breast cancer diagnosis, menopausal status at time of diagnosis, or type of cancer treatment (radiotherapy or chemotherapy or endocrine treatment). The treatment effect was significantly greater in women not receiving chemotherapy, those with higher levels of psychological distress at baseline and for non-white women. Beliefs about control/coping with hot flushes were the main mediators of improvement in problem rating following CBT. Beliefs about hot flushes in a social context, depressed mood and sleep problems were also identified as mediators.

Conclusions

These findings suggest that CBT is widely applicable for breast cancer patients who are experiencing treatment related menopausal symptoms, and that CBT works mainly by changing beliefs and improving mood and sleep.     

Phytoestrogens for menopausal symptoms: a review

Objective

To review the evidence that isoflavones are effective treatments for menopausal symptoms and to present the safety data.

Methods

The databases Scopus, ScienceDirect and Primo Central Index were searched and preference was given to systematic reviews and meta-analyses.

Results

The available evidence suggests that isoflavones do not relieve menopausal vasomotor symptoms any better than placebo. Long-term safety studies suggest that women who consume a diet high in isoflavones may have a lower risk of endometrial and ovarian cancer.

Conclusions

Isoflavones cannot be recommended for the relief of hot flushes.     

Aerobic exercise as a treatment for vasomotor menopausal symptoms: Randomised controlled trial protocol

Background

Evidence suggests that a high proportion of perimenopausal and postmenopausal women experience vasomotor symptoms (hot flushes/night sweats) that can be severe and disruptive and which are the principal reason for seeking medical intervention. Hormone therapy (HT) is known to be an effective treatment for troublesome hot flushes/night sweats but research has raised questions about the safety of HT and there have been negative high profile media reports about its use. Consequently many women are seeking alternatives and exercise might be one such option but there is a lack of high quality evidence on its effectiveness.

Aims

This RCT initially aims to investigate the feasibility/acceptability of two exercise interventions identified from our previous preference study in 165 women, and if found to be feasible/acceptable, continue to recruit sufficient women (n = 261) to examine the effect of these interventions on hot flushes/night sweats and other outcomes relevant to menopausal women.

Method

We aim to recruit inactive perimenopausal and menopausal symptomatic women not using HT and randomise them to one of two exercise interventions or usual care for six months.

Results

We will assess outcomes at baseline and 6 and 12 months from randomisation.

Conclusion

We hope this RCT will contribute towards increasing the evidence regarding the question of whether exercise is an effective treatment for vasomotor symptoms in women not taking HT.     

Menopausal symptoms following breast cancer treatment: A qualitative investigation of cognitive and behavioural responses

Objectives

Menopausal symptoms – hot flushes and night sweats (HF/NS) – are particularly troublesome for women who have undergone breast cancer treatment. Non-medical treatments, such as cognitive behaviour therapy, are being developed but there is a lack of information about cognitive and behavioural reactions to HF/NS in breast cancer patients.

Methods

Thirty-five women who had completed active breast cancer treatment with at least 10 HF/NS per week completed questionnaires assessing HF/NS, mood and beliefs, and took part in interviews to elicit cognitive and behavioural reactions and a thematic content analysis used to analyse the data.

Results

The mean weekly frequency of HF/NS was 76 (SD = 46) (57 HF and 19 NS). Smokers reported significantly more night sweats, but BMI and mood were not associated with HF/NS frequency. Cognitive and behavioural responses were varied but broadly similar to those of well women. The main cognitive themes were: embarrassment/social anxiety, loss of control, beliefs about NS, sleep and tiredness, and the main behaviours were: carry on and ignore them, cool down, avoidance, communication with others.

Conclusions

The results are discussed within a cognitive behavioural framework and might inform the development of psychological interventions for these treatment related symptoms.     

Cardiovascular autonomic responsiveness in postmenopausal women with and without hot flushes

Objectives

During menopausal transition autonomic balance is known to shift towards sympathetic dominance, but the role of vasomotor hot flushes in this phenomenon is not understood. We compared cardiovascular autonomic responsiveness between women with and without hot flushes.

Study design and main outcome measures

One hundred fifty recently postmenopausal healthy women with varying degree of hot flushes (none, mild, moderate, severe) underwent comprehensive cardiovascular autonomic nervous testing (controlled and deep breathing, active orthostatic test, Valsalva manoeuvre and handgrip test) assessing both sympathetic and parasympathetic activity. The responses of heart rate, heart rate variability and blood pressure in these tests were evaluated.

Results

Responses in heart rate showed differences between the study groups only in the Valsalva manoeuvre where the tachycardia ratio in all symptomatic women was lower (p = 0.041) than in women without hot flushes. Neither change in the heart rate variability analyses nor the blood pressure responses were affected by hot flush status. However, there was a non-significantly higher maximum systolic (140 (112–182) mmHg vs. 135 (102–208) mmHg) and diastolic blood pressure (94 (72–112) mmHg vs. 90 (66–122) mmHg) following the handgrip test in women without hot flushes vs. all the symptomatic women.

Conclusions

Menopausal hot flushes seem to be associated with a possibly increased sympathetic preponderance without an effect on parasympathetic activity in cardiovascular autonomic responses. This may imply a potentially negative impact on cardiovascular health in women experiencing hot flushes.     

Sleep quality and aerobic training among menopausal women--a randomized controlled trial

Background

Menopause is associated with poor sleep quality and daytime sleepiness, which may lead to impaired quality of life and impaired functioning in daily activities.

Objective

To study whether exercise training improves sleep quality or decreases the amount of night time hot flushes among menopausal women with vasomotor symptoms.

Study design

A randomized controlled trial. Sedentary women (N = 176) aged 43–63 years with menopausal symptoms were randomized to a six-month unsupervised aerobic training intervention (50 min 4 times per week) or a control group. Both groups attended lectures on physical activity and health once a month.

Main outcome measures

Sleep quality and the amount of hot flushes disturbing sleep. The women reported daily via mobile phone whether hot flushes had disturbed their sleep and how they had slept (scale 1–5). Responses received by mobile phone over the 6-month period totaled on average 125 (5.2 per week) responses per participant.

Results

At baseline there was no difference between the groups in the demographic variables. Sleep quality improved significantly more in the intervention group than in the control group (OR 1.02; 95% CI = 1.0–1.05, p = 0.043). The odds for sleep improvement were 2% per week in the intervention group and a decrease of 0.5% per week in the control group. The amount of hot flushes related to sleep diminished (p = 0.004) by the end of the intervention.

Conclusions

Aerobic training for 6 months may improve sleep quality and reduce hot flushes among symptomatic menopausal women.     

Managing hot flushes in men after prostate cancer—A systematic review

Context and objective

The aim of this study was to describe hot flushes in men with prostate cancer, and their treatment methods.

Method

A systematic review was conducted of the literature indexed between 1966 and 2009 on the MEDLINE, the ISI Web of Knowledge, Cinahl and PsycINFO. Of 252 articles identified, 32 were selected for consideration of their complete texts, of which five were subject to detailed analysis.

Results

Diethylstilbestrol, megestrol acetate and cyproterone acetate have the strongest effect, giving a 75% or larger decrease of the number of hot flushes, but they may have severe or bothersome side-effects. Gabapentin has an uncertain effect. Clonidine is not proven effective for hot flushes. Long-term effects were not evaluated in any of the studies. SSRI/SNRI and acupuncture may have a moderate effect on hot flushes but are not proven in any RCTs.

Conclusion

Hot flushes are common and bothersome symptoms in men with prostate cancer and those taking anti-androgen treatment, and reduce quality of life. Few treatments are available and some are avoided for these patients. Additional prospective treatment studies are needed, with long-term follow-up, in order to evaluate the effects and risks of treatments. Treatments with few or no severe side-effects should be prioritised in future investigations. Experimental studies are also needed to elucidate the mechanism behind hot flushes in men and to suggest routes for the development of new treatments.     

Knowledge of the health consequences of obesity among overweight/obese Black and Hispanic adults

Objective

To measure knowledge of the health consequences of obesity among overweight/obese Black and Hispanic adults and examine the relationship to prior weight loss.

Methods

Knowledge of the health consequences of obesity was assessed among 410 Black and Hispanic adults with BMI ≥ 25 kg/m² enrolled in a behavior change weight loss study. The relationship between obesity risk knowledge and previous weight loss was also examined.

Results

The majority of participants were knowledgeable of the risk of hypertension (94%), diabetes (96%), high cholesterol (91%), joint pains/arthritis (89%) and sleep apnea (89%) associated with obesity. Among post-menopausal age women, 53% were aware of the increased risk of breast cancer. There was no significant relationship between obesity risk knowledge and previous weight loss of 10 pounds or more (OR = 1.075, 95% CI: [0.808, 1.430]).

Conclusions

We found that knowledge of the health consequences of obesity was high, except for knowledge of the risk of breast cancer. Obesity risk knowledge was not associated with past weight loss.

Practice implications

Further health education is needed regarding the increased risk of breast cancer associated with obesity. Our data suggest that knowledge of the health consequences of obesity is not associated with weight loss success.     

The Asian Menopause Survey: Knowledge,perceptions, hormone treatment and sexual function

Objective

To provide current insights into the opinions, attitudes, and knowledge of menopausal women in Asia regarding menopause and hormone replacement therapy (HRT).

Study design

Cross-sectional.

Main outcome measures

Between January 2006 and February 2006, 1000 postmenopausal women from China, Malaysia, Taiwan, Thailand and Hong Kong were interviewed to determine postmenopausal symptoms, HRT use and knowledge, breast discomfort and knowledge of breast cancer risks, and sexual function.

Results

Almost all women reported experiencing postmenopausal symptoms. Sleeplessness (42%) was reported as the main reason for seeking treatment. On average, 54% of women were aware of HRT, despite the fact that most (38%) were unable to mention any associated benefits. Most women had used natural or herbal treatments (37%) for the alleviation of menopausal symptoms. Only 19% had received HRT. 27% of respondents reported having breast discomfort, while 70% reported performing self-breast examinations. 53% of women had never received a mammogram, despite breast cancer concern (50%). 24% of women described HRT as being a risk factor for breast cancer. Most women and their partners reported no reductions in sexual function (66 and 51%, respectively), while 90% of respondents did not seek treatment for reduced sexual function. In the event of sexual dysfunction, 33% of women replied that they would be willing to seek treatment.

Conclusions

Many Asian women experience postmenopausal symptoms that are often left untreated (due to the acceptance of menopause as a natural process) or treated with herbal/natural remedies. There was a general lack of knowledge among these women regarding treatment options, HRT, and possible risks associated with HRT. A more concerted effort should be made to better disseminate information regarding the pathogenesis and risk factors associated with breast cancer, menopause, and menopausal symptoms to Asian women.     

Treatment-related and psychosocial variables in explaining physical activity in women three weeks to six months post-treatment of breast cancer

Objective

This study examined treatment-related and psychosocial variables in explaining total and leisure time physical activity in breast cancer survivors three weeks to six months post-treatment.

Methods

A questionnaire was used to measure total and leisure time physical activity and relevant determinants among 464 breast cancer survivors (aged 18–65 years).

Results

Personal control was an important overall determinant in explaining physical activity in breast cancer survivors. The impact of treatment-related variables and psychological functioning depended on the working status of the women. Fatigue and poor body image prevented non-working women from being sufficiently physically active. In working women, chemotherapy and arm problems negatively influenced physical activity, whereas therapy side-effects (headaches, hot flashes, feeling unwell) and poor body image positively influenced physical activity. Social support and coping strategies could not explain post-treatment physical activity levels.

Conclusion

Personal control, treatment-related variables and psychological functioning influenced physical activity after cancer treatment. Relations depended on the working status of the women.

Practice implications

Incorporating self-control methods in physical activity interventions after breast cancer could be helpful. Furthermore, interventions should be tailored to the experienced symptoms (fatigue, arm-problems, body image) and working status of women.     

What women want? Exercise preferences of menopausal women

Background

Many menopausal women are keen to find alternatives to HRT; exercise might be useful in this regard but more trial evidence is required. Before we conduct such trials however, it is important to understand the exercise preference of these women so that appropriate exercise interventions can be developed for inclusion in such trials.

Aim

To investigate the exercise preferences of menopausal women and to examine the association between exercise levels, BMI, and hot flushes/night sweats in this population.

Method

Participants were women aged 46–55 years from eight diverse general practices in Birmingham. A postal questionnaire containing items about demographics, lifestyle behaviours, weight, height, menopausal status, frequency of hot flushes/night sweats and preferences for exercise was sent to all eligible women.

Results

1693/2776 (61.0%) of women replied. The majority (75.9%) of respondents stated that exercise was an acceptable intervention. The most commonly chosen option for delivery of exercise interventions was by one-to-one consultations with a fitness advisor, followed by DVD sent by post. Telephone based interventions and e-Health interventions (i.e. Internet and mobile phone text messages) were the interventions least chosen. There was also an overwhelming choice for walking as a mode of exercise. A series of two factor analyses of covariance indicated exercise participation and BMI were not significantly related to frequency of hot flushes/night sweats in symptomatic menopausal women.

Conclusion

Menopausal women have strong preferences to receive exercise interventions that involve one-to-one contact with a fitness advisor or by exercise DVD. The use of more recent technology to deliver exercise interventions was highly unpopular. These findings should be considered in future studies when planning exercise interventions with this population.     

Perception of cancer recurrence risk: More information is better

Objective

Breast cancer is the most common cancer among women worldwide. Given the advances in extending survival, the number of recently diagnosed breast cancer patients and longer-term breast cancer survivors is growing. The goals of this study were to better understand (1) perceptions of provider cancer recurrence risk communication, (2) perceived risk of breast cancer recurrence in cancer patients and survivors, and (3) accuracy of perceived risk.

Methods

A survey was conducted on women with a prior breast cancer (n = 141).

Results

Approximately 40% of women perceived that providers had not talked about their breast cancer recurrence risk; although only 1 person reported not wanting a physician to talk to her about her risk. Women were largely inaccurate in their assessments of risk. Greater worry, living in a rural area, and longer time since diagnosis were associated with greater inaccuracy. Women tended to think about distal recurrence of cancer as often of local recurrence.

Conclusions

Perceived risk of breast cancer recurrence was inaccurate, and patients desired more communication about recurrence risk.

Practice implications

Consistent with findings from other studies, greater efforts are needed to improve the communication of cancer recurrence risk to patients. Attention should be paid to those from rural areas and to distal cancer recurrence in women with a previous history of breast cancer.     

Big gap between risk perception for breast cancer and risk factors: Nationwide survey in Korea

Objective

To explore perceived risk of breast cancer among Korean women and to investigate factors associated with perceived risk of breast cancer.

Methods

A telephone survey using random digit dialing was conducted with an age- and region-stratified random sample of women in Korea. The study population consisted of 1000 women who participated in telephone surveys in which a 21-item questionnaire was administered.

Results

This study showed a significant level of comparative optimism in breast cancer risk perception in Korean women with an average risk of breast cancer. According to the multivariate analysis, younger age, family history of breast cancer, and history of benign breast disease were the factors associated with higher perceived comparative risk of breast cancer.

Conclusion

The finding that a limited number of breast cancer risk factors were related to perceived risk of breast cancer is worrying because women with other risk factors for breast cancer may believe themselves to be at lower risk.

Practice implications

It is necessary for women to understand their risk factor profiles to avoid biased optimism or pessimism.     

Self-compassion weakens the association between hot flushes and night sweats and daily life functioning and depression

Objectives

Some women find hot flushes and night sweats (HFNS) to interfere more in daily life and mood than others. Psychological resources may help to explain these individual differences. The aim of this study was to investigate the role of self-compassion, defined as healthy way of relating toward the self when dealing with difficult experiences, as a potential moderator of the relationship between HFNS and daily life activities, which in turn influences symptoms of depression.

Study design

This was a cross-sectional study using questionnaire data from 206 women aged 40–60 who were currently experiencing hot flushes and/or night sweats. Path analysis was used to model relationships among menopausal factors (HFNS frequency and daily interference ratings), self-compassion and mood.

Main outcome measure

Hot flush interference in daily activities and depressive symptoms.

Results

On average, women experienced 4.02 HFNS per day, and HFNS frequency was moderately correlated with interference ratings (r = 0.38). In the path analytic model, self-compassion made significant direct contribution to hot flush interference ratings (β = −0.37) and symptoms of depression (β = −0.42), and higher self-compassion was associated with lower interference and depressive symptoms. Self-compassion also moderated the relationship between HFNS frequency and hot flush interference. Higher self-compassion was associated with weaker effects of HFNS frequency on daily interference.

Conclusions

Self-compassion may weaken the association between HFNS and daily life functioning, which in turn, could lead to less HFNS-related mood problems. These findings imply that self-compassion may be a resilience factor to help women manage hot flushes and night sweats.     

The effect of synthetic genistein on menopause symptom management in healthy postmenopausal women: a multi-center, randomized, placebo-controlled study

Objective

To evaluate the efficacy of synthetic genistein for reducing the frequency and severity of hot flushes.

Study design

A 12 week randomized double-blind, placebo-controlled study in which 84 postmenopausal women received placebo or a single 30 mg dose of synthetic genistein.Outcome measures primary: percentage change in the number of daily hot flushes from pre-treatment to week 12. Secondary: duration and severity of daily hot flushes, Greene Climacteric Scale score, serum follicle stimulating hormone (FSH), 17β-estradiol and endometrial thickness.

Results

Genistein supplemented subjects completing at least 4 weeks on trial (n = 40) demonstrated a 51% reduction (9.4–4.7/day) in the number of hot flushes by week 12 compared to a 27% reduction in the placebo group (9.9–7.1/day) (p = 0.026). Subjects in the genistein group also reported significantly fewer hot flushes per day (p = 0.010) and a decrease in total duration of hot flushes per day (p = 0.009) at week 12 versus placebo. Subjects on genistein (n = 32) completing 12 weeks on trial demonstrated a 51% reduction (9.7–4.7/day) in the number of hot flushes by week 12 (p = 0.049) compared to 30% reduction in the placebo group (9.8–7.0/day) and had fewer hot flushes per day and a decrease in total duration of hot flushes per day at week 12 compared to placebo (p = 0.020 and p = 0.017, respectively). There were no differences between groups in Greene Climacteric Scale, FSH, 17β-estradiol, endometrial thickness or adverse events.

Conclusions

The current study provides the first evidence that a single daily dose of 30 mg of synthetic genistein reduces hot flush frequency and duration.     

Effects of black cohosh on the plasminogen activator system in vascular smooth muscle cells

Objective

The rhizome of the Cimicifuga racemosa plant (commonly known as black cohosh) has been used for menopausal complaints. Studies regarding the cardiovascular effects of black cohosh are lacking. We investigated the effect of black cohosh on the plasminogen activator system in cultured vascular smooth muscle cells (VSMCs).

Methods

VSMCs were isolated from rat aortae. Expression of plasminogen activator inhibitor type 1 (PAI-1) and tissue-type plasminogen activator (t-PA) proteins were evaluated by Western blot analysis and enzyme-linked immunosorbent assay, respectively. The activities of PAI-1 and t-PA in the conditioned media were assessed by fibrin overlay zymography. A 40% 2-propanol extract of black cohosh was used.

Results

Black cohosh extract (BcEx) stimulated the protein expression of PAI-1, but it did not affect that of t-PA. Vitamin E, a potent antioxidant, inhibited the BcEx-induced increase in PAI-1 expression, while ICI 182,780, an estrogen receptor antagonist, had no effect. Fibrin overlay zymography revealed that BcEx increased the activity of PAI-1 in the conditioned media, while concurrently decreasing that of free t-PA by inducing a binding to PAI-1.

Conclusions

BcEx induces PAI-1 protein expression in the VSMCs likely via an oxidant mechanism. It also stimulates the enzyme activity of PAI-1 and reduces that of free t-PA. These findings suggest that black cohosh might exert a negative influence on fibrinolysis.     

Suspected black cohosh hepatotoxicity—Challenges and pitfalls of causality assessment

Objectives

Black cohosh (BC) is a herbal drug or herbal dietary supplement used for treatment of menopausal symptoms. Recently, however, reports have appeared about the occurrence of rare toxic liver disease in an assumed relationship with the use of BC.

Methods

We have analyzed and reviewed the data of all 69 reported cases with suspected BC hepatotoxicity. Causality for BC was assessed utilizing the scale of the original structured quantitative Council for International Organizations of Medical Sciences (CIOMS), or the main-test as its updated form.

Results

With the hepatotoxicity specific causality assessment methods, there was an excluded, unlikely, unrelated or unassessable causality for BC in 68 of 69 cases with liver disease. One patient had a possible causality for BC and a symptomatic cholelithiasis with confounding variables of fatty liver of unknown etiology; unknown BC brand including possible herbal mixture; unknown daily BC dosage; and an unassessable duration of BC usage. In general, the cases of the 69 patients were poorly documented. Confounding variables were: failure to identify the BC product; use of herbal mixtures with multiple ingredients in addition to BC; co-medication with synthetic drugs and dietary supplements including herbal ones; missing temporal association between BC use and development of liver disease; not specified modalities of BC treatment; failure of dechallenge after BC discontinuation; pre-existing liver diseases; insufficiently excluded other liver diseases; presence of alternative liver diseases.

Conclusions

The analysis of 69 cases shows little, if any, supportive evidence for a significant hepatotoxic risk of BC.     

Efficacy and tolerability of estradiol 1 mg and drospirenone 2 mg in postmenopausal Korean women: a double-blind, randomized, placebo-controlled, multicenter study

Objectives

The aim of this study was to demonstrate that the therapeutic efficacy of an estradiol 1 mg/drospirenone 2 mg (E2/DRSP) preparation is superior to a placebo in postmenopausal Korean women with hot flushes and other climacteric symptoms, and to demonstrate that this treatment is both safe and tolerable.

Methods

This was a double-blind, randomized, placebo-controlled, multicenter study over four 28-day treatment cycles. A total of 158 subjects were screened and 90 women were randomized into two treatment groups (E2/DRSP group, n = 45; placebo group, n = 45). The primary efficacy parameter was the individual relative change of hot flushes. The secondary efficacy parameters such as other climacteric, urogenital symptoms and vaginal bleeding patterns were also evaluated, and the occurrence of any adverse events was noted. In addition, physical, gynecological examinations and laboratory analyses were performed at the beginning and end of the study.

Results

The mean number of hot flushes per week during treatment weeks 3–16 decreased by 48.1% during treatment with placebo, and by 84.4% during treatment with E2/DRSP (p < 0.001). The E2/DRSP combination also reduced the incidence and intensity of menopausal symptoms in postmenopausal women. Most of adverse events was mild or moderate degree of intensity. None of the parameters measured in the study, including laboratory analyses, physical and gynecological examinations, vital signs, and weight, led to any concerns of safety.

Conclusions

The E2 1 mg/DRSP 2 mg combination tested in the study was efficacious and safe in the treatment of hot flushes and other climacteric symptoms in postmenopausal Korean women.     

"Seeing is believing, and believing is seeing": an exploration of the meaning and impact of women's mental images of their breast cancer and their potential origins

Objective

To explore the nature, meaning and perceived origin of women's mental images of their breast cancer.

Methods

Fifteen women, who had completed treatment for primary breast cancer, participated in this qualitative in-depth interview study. Data were analysed using a constant comparative technique within the “Framework” method.

Results

Almost all women had a mental image of their cancer. Images reflected their beliefs about their illness (its appearance, character and dangerousness) and appeared to be related to a number of fears and concerns. The origin of images was uncertain but appeared to be influenced by scan images, verbal metaphors presented by health professionals, and previous beliefs held about cancer. Some women used metaphors presented to infer properties of the cancer that may have been unintended by the health professional.

Conclusion

Women may have mental images of their breast cancer that are associated with hope, reassurance, anxiety, despair, or views about the future. Further longitudinal research is required to establish the origin and importance of these images.

Practice implications

Health professionals may find that exploring women's mental images of their cancer is a helpful way of identifying potential misunderstandings about their illness.